METHODS
Thoracoscopic procedure was performed starting from the chest side in which LAA was promptly approachable: the right side. Two 10-mm ports and one 5-mm port were placed along the right anterior axillary (3th and 5th intercostal space) and mid-axillary line (4th intercostal space) as previously described for classic anatomy procedures.3,4 Briefly, once the pericardium was opened, the LAA was visualised as reference. A blunt dissection at the level of the roof of the LA was performed to allow the right curved bipolar ablation device (Isolator Synergy Clamp, EMR2; AtriCure Inc, Mason, OH USA) to encircle the PV on the right side (Figure 2A). The device followed the route previously prepared by means of a track-light dissector (Lumitip, AtriCure Inc, Mason, OH USA). Connecting lesions were then performed by using a linear bipolar radiofrequency device (Coolrail linear pen, AtriCure Inc, Mason, OH USA) at the level of the inferior side of the Box Lesion (Figure 2B). LAA occlusion was performed by means of AtriClip Pro 2 device 40 mm (AtriCure Inc, Mason, OH USA). We then moved ports to the contralateral side in order to complete the thoracoscopic surgical ablation (Figure 2C).
A blunt dissection of the pericardial reflection below the confluence of the two sovra-hepatic veins (draining into the RA) was performed in order to gain access to the oblique sinus (Figure 3A). The access to the transverse sinus was obtained by gently dissecting the pericardial reflection below the SVC. PVs at the left side were encircled and RF energy was delivered by means of left curved bipolar ablation RF device (Isolator Synergy Clamp, EML2 AtriCure Inc, Mason, OH USA) (Figure 3B). Once completed, connecting lesions between right and left PVs were performed at the level of the roof of the LA (Coolrail, AtriCure Inc, Mason, OH USA). Exit block was confirmed at the end of the procedure with a total surgical time of 200 minutes.
RESULTS Intra-operatively and during hospitalization no complications occurred. The patient was discharged in sinus rhythm after four days. At three and twelve months follow-up, the patient was in stable sinus rhythm without experiencing recurrent symptomatic episodes of AF, as confirmed by means of holter-ECG evaluation.